An introduction to Italian healthcare: Organization, health status and healthcare expenditure

The GDP in Italy in 2015 was €1,624 bn, with a growth rate of 0.5%, equivalent to a GDP per capita of €26,495. Based on GDP, Italy is amongst the 10 largest economies in the world, and amongst the 5th largest in Europe. Quality of life indicators are generally high; however, there are substantial regional discrepancies.

Healthcare organization

Healthcare in Italy is provided by a mixed public-private system and is largely decentralized. This decentralized approach, introduced in the 90s, has led to differences in funding, priority setting, DRG tariffs and copayment levels.

Within the various regions, public funds are allocated to public, as well as accredited private hospitals. Approximately 40% of all acute hospitals are accredited private hospitals that provide care services to the National Health Service (Servizio Sanitario Nazionale, SSN).

In total there are around 1,050 hospitals. Just under half are public hospitals, managed directly by the local health authorities, operated as semi-independent public enterprises or has healthcare trusts.

Public hospitals often face significant debt situations, and reimbursement delays of one year or more are common.

Nonetheless, in terms of coverage, and health status, the Italian healthcare system scores very high and ranks amongst the top healthcare providers worldwide.

How does the Italian government and Italian regions administer healthcare?

19 regions and the 2 autonomous provinces are responsible for the organization and delivery of health services through 21 regional health authorities (ASR). They have a significant autonomy in determining the structure of their health system.

The central government allocates tax revenues for publicly financed healthcare (SSN) and defines a national minimum “statutory benefits” package (LEA) in accordance with the Ministry of Health (MOH) for all residents in every region.

Various institutions assist the MOH with technical support related to national health planning, public health, pharmacology, reimbursement policies, medical education and information systems.

Some regions have created agencies to evaluate and monitor the local healthcare. At the local level, the Local health authorities (ASL) are managed by a director appointed by the governor of the respective region.

The local health authorities deliver primary care, hospital care and tertiary care. There are 200 ASLs and they run the majority of the acute hospitals. In addition there are approximately 105 health trust hospitals.

A current trend reflects a regional return to integration, through the adoption of formerly independent hospitals by ASLs, and a tighter engagement/management of providers.

Public and private healthcare interaction

Specialist consultations and diagnostic tests are provided by public or accredited private hospitals. The waiting times in the public sector are substantial: they can go up to a few months for consultations, tests and elective surgery. In contrast, the waiting times in the private sector generally do not exceed a few weeks.

The Italian healthcare system allows ASLs to freely buy services from public or private providers, which creates a certain level of competition between hospitals.

Next to the public segment there are over 400 private hospitals of which most are accredited by the SSN (80%). To assure sufficient healthcare capacity, the local health authorities buy care services from these accredited hospitals.

How is Italian healthcare funded?

The healthcare system is funded through income taxes (national) and VAT (regional). The healthcare providers are financed through fixed allowances (from central and regional governments) and by a DRG-like reimbursement system.

General practitioners are paid by the SSN. Patients are registered at a general practitioner who will be the gatekeeper for further referrals. Centralized purchasing activities and supra-organizational structures are also growing more prevalent.

Public expenditure distribution

The Northern and Southern regions on average have a distinct distribution from one another on hospital and preventative care.

  • The North spends 55% on local care (preventative, primary care, etc.), compared to 50% in the South
  • The North spends 50% on hospital care, compared to 45% in the South
  • The North spends 6.5% of its GDP on healthcare, compared to 9.5% in the South

Private expenditure

  • 82% of private expenditure is OOP

The high share of OOP spending is accounted for by a lack of provisions in the public sector. Respectively, the following are paid for and handled by the private sector without involvement from the SSN:

  • 92% of dental care
  • 58% of diet-related care
  • 63% of gynecological care

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